Insurance Fraud Referral Form

Insurance Fraud Referral Form

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Insurance Fraud Referral Form

 

INSTRUCTIONS: CONNECTICUT INSURANCE FRAUD REPORT

 

 

If you suspect insurance fraud in Connecticut, a report should be filed with the state insurance department. The document discussed in this article can be obtained from the website maintained by the government of the state of Connecticut.

 

Connecticut Insurance Fraud Report Step 1: The first section concerns the person submitting the report. In the first three blank boxes, enter the name of the person submitting the report, the date, and the SIU file number.

 

Connecticut Insurance Fraud Report Step 2: In the next three blank boxes, enter the name of the company of the person reporting (if applicable), the name of a contact person, and a phone number.

 

Connecticut Insurance Fraud Report Step 3: In the next four blank boxes, enter the street address, city, state and zip code of the person reporting.

 

Connecticut Insurance Fraud Report Step 4: Indicate with a check mark whether you are reporting for informational purposes only or if you require assistance from the department of insurance.

 

Connecticut Insurance Fraud Report Step 5: The next section requires information about the insurance policy. In the first two blank boxes, enter the name of the insurer and the name of the insured or policyholder.

 

Connecticut Insurance Fraud Report Step 6: Enter the policy number, line of business, effective date and expiration date in the next four blank boxes.

 

Connecticut Insurance Fraud Report Step 7: The next two blank boxes should only be completed if the policy in question is a group insurance policy. If so, enter the name of the member and the certificate number.

 

Connecticut Insurance Fraud Report Step 8: In the next three blank boxes, enter the name of the claimant, the claim number and the date of the loss.

 

Connecticut Insurance Fraud Report Step 9: The next section requires information about the suspect. Enter their name, Social Security number, tax identification number, address and all other requested identifying information.

 

Connecticut Insurance Fraud Report Step 10: In the blank section provided, provide a brief description of the suspected fraudulent activity.

 

Connecticut Insurance Fraud Report Step 11: In the next blank section, list all law enforcement agencies and other authorities who have been advised of the suspected fraudulent activity.

 

Connecticut Insurance Fraud Report Step 12: You may list additional information on the second page, as well as any action you are requesting the department of insurance to take.


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